William H. Wehrmacher, MD, FACP, FACC
Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States
|Photography and collage by Tom Magliery|
As we vigorously plunge into our third millennium, we may gain some guidance by carefully examining the pathway experienced during the 20th century. During the first half of the 20th century, civilization expanded and improved explosively, progressing substantially in communication, transportation, food production, and manufacturing. Medical societies, publications, and teaching institutions accumulated substantial advances in scientific research in the biologic, physiologic and psychological areas, and in social processes.1
In 1900 the national debt was only $1.2 billion and per capita debt was only $16.60. By 2000, however, that debt had inflated to $5,674.2 billion and the debt for every citizen had ballooned to $20,108.2 The interest payment required for that debt has already become an exceptional burden. It has reduced the funds available for supplying the services, needs, and products for its citizens. According to an e-mail from the Heritage Foundation reported in 2012, this yearly cost for interest payment exceeds the amount spent by each of several individual U.S. Departments: Agriculture, Labor, Veteran’s affairs, Transportation, Education, and Homeland Security.
The major wars demonstrated limited, if any, benefits. World War II alone killed 60 million people and left the belligerents impoverished. Can such catastrophes be avoided in this third millennium?
In 1900 the average life expectancy at birth was 48.3 years. By 2000 it had increased to 76.9 years. Improved sanitation and medical care initiated this increase, and improvements in both propelled it. Unlike the increased life expectancy demonstrated from birth, life expectancy for people after retirement age did not improve after the mid 1800’s through the first two thirds of the 20th century. Substantial improvement was shown in the last third of the century.3 Improved life expectancy was greatly appreciated by individuals, while the need for new and revised social planning has been substantially and dangerously delayed.
When Sir William Osler lectured in 1906 on “the fixed period,” he said: “the effective, moving, vitalizing work of the world is done between the ages of twenty-five and forty,” and it is downhill from then.” His speech, delivered when he was about 50 years old, was portrayed by newspapers with headlined reports, “Osler recommends chloroform at sixty.” Failing to recognize in his address and writings4 the continuing contributions by the elderly, he perhaps he should have recognized Sophocles’ (497–406 BC) writing of the “Oedipus at Colos” in his 90th year, and Galileo’s (1564–1642 AD) writings at age 82. Some of Osler’s contemporaries, including Alexander Graham Bell and Henrik Ibsen, could also have reminded him of their continuing contributions when elderly.
During the last third of the 20th century, people began to recognize the importance of improving circumstances for the aging. They developed active research on the elderly, understanding that aging was not simply deterioration, but rather that much was the consequence of injury, disease, and functional disturbance. Recognition of these consequences showed the way to prolong survival, but unfortunately not how to deal with its expenses and need for special facilities.
Women’s role evolved more stunningly than at any other time in history. Every aspect of daily life improved, from the domestic sphere to their public presentation. At its beginning, a woman’s main goal was to marry and care for her husband and children. In a subservient role with few rights, they were weighed down with heavy domestic work within the home, lacking running water, electricity, and other household aids. Women were constantly cleaning, washing, scrubbing, cooking, sewing, tending to children, and dealing with household finances.5
Although for centuries women had unsuccessfully sought for equal rights with men, the achievement became virtually complete during the 20th century. During World War II women were propelled by necessity into the workforce, exposing them to previously male-dominated work at all levels. Having proved their ability to succeed, the women’s equal rights movement, joined by new women’s organizations, pushed, as women began competing with men for positions in all areas: labor, arts, science, politics, and the professions. Their success began the transformation of the traditional patriarchal social structure around the globe. By the midpoint of the twentieth century, women’s’ activities and concerns had been recognized as a significant element of the literary, scientific, and cultural landscape of several countries, marking a revolutionary change in the social and domestic roles of women.
Other significant developments were planned parenthood and birth control. At the beginning of the century, birth control was seen as immoral, believing that women did not have the right or ability to control family size, but rather it was the responsibility of the husband, the government, or perhaps God, Himself, to decide who should bear a child, and it was considered murder to tamper with pregnancy. Pregnancy prevention techniques were thought “obscene.” Nonetheless, effective contraceptives became generally available before mid-century, despite some continuing opposition.
By end of the century, some poorly-resolved questions remained: whether the response of women6 to cardiovascular surgery was equivalent to that of men and whether insufficient attention was being devoted to atherosclerotic and thromboembolic disease. At the beginning of the century, vascular disease had been thought to spare most women, but before its end, it became clearly evident that it was an important cause of death.7
During the century, women have become engaged more fully in economic, professional, and political life. Nonetheless, despite their gains toward equal opportunity, some tensions continue to remain between public and private roles of equality for women.
During the 20th century, forward movements in electronics, computer science, metallurgy, engineering, chemistry, and physics rapidly reinforced progress in the medical sciences.
Roentgen’s discovery of the utility of the x-rays to peer into the human body non-invasively in the late 19th century became the basis for further progress in the 20th century. The development of computed scanning, magnetic resonance imaging, and ultrasound to image virtually every part of the human body has transformed the entire practice of medicine. Risks of radiation were recognized only much later, and both medical radiation exposure and isotopic radiation exposure continue to require special attention.
Laboratory procedures for measuring the chemical content of body fluids and enumerating the formed elements of the blood were already well developed before the beginning of the 20th century, but were cumbersome, time-consuming, and labor-intensive. They became readily and rapidly available, in automatic systems, and widely used to the benefit of both physicians and patients.
Drug therapy had been well established in ancient times, but was mainly empiric. In the United States, the first chair in pharmacology was established at the University of Michigan in 1890 under John Jacob Abel, who had trained under Schmiedeberg. In 1893 Abel went to Johns Hopkins University in Baltimore, where he had a long and brilliant career. His major accomplishments include isolating epinephrine from adrenal gland extracts (1897–1898), isolating histamine from pituitary extract (1919), and preparing pure crystalline insulin (1926).
Pharmacologic research8 intensified and steadily provided great numbers of new therapeutic drugs during the 20th century, but also increased their cost. Autonomic nervous system agents, angiotensin-converting enzyme inhibitors and receptor blockers, adrenergic blocking drugs, and calcium channel blockers appeared by mid-century. Digitalis, introduced by William Withering’s in the late 18th century for treating heart failure, was confirmed in the 1994 DIG report9 as effective in reducing symptoms and the need for hospitalization, but failed to provide evidence that it prolonged life. In recent years its use has been greatly reduced as it has been replaced by other cardiac drugs.10,11
Elevated cholesterol levels became recognized as the source of atherosclerotic plaques in blood vessels and generated the search for a remedy. The drug MER-29 (triparanol) blocked part of cholesterol’s synthetic pathway and became widely prescribed after its discovery in December of 1959. It was soon recognized to cause serious side effects,12 and was quickly replaced by HMG-CoA reductase inhibitors and statins, which have continued to show promise for delaying the complications of arteriosclerosis. In diabetics, new classes of drugs (e.g., sulfonylureas, thiazolidinediones biquanides, and newer adjunctive classes) have also appeared and may help delay or prevent cardiovascular complications.
Surgery also made great advances during the 20th century, particularly on the heart and brain. Electronic cardiac pacemakers were introduced in mid-century. In 1960 the first hip replacement surgery was accomplished. In 1962 a boy had his severed arm reattached in the first successful reattachment surgery. The first heart transplant was performed in 1967. The first artificial heart was installed in 1982. The first heart and lung transplant was done in 1987.
Parts of the 20th century radiated brightly although with some dark gloom in between. Both deserve scrutiny as we seek overall brightness for the third millennium.
- Wehrmacher, WH. “Medicine since 1900” :In:The Growth of Medicine. Ed., F. Stenn. Springfield: Charles C. Thomas, 1967
- World Almanac 2005
- Wehrmacher, William H and Ahmed A. “A brief history of Scientific Geriatric Cardiology”.. Comprehensive Therapy 2008: Vol 34(2) 100-45
- Osler, W "Aequanimitas, with other Addresses to Medical Students."). 2ndedition, 1906. Blakiston's sons and Company publisher
- Randall Bellows, MD, Wehrmacher, WH.. “A Woman’s Body and Her Vascular System are Unique. How Should We Care for Them?” Comprehensive Therapy 2004; 30 (3) p. 155-158
- Wehrmacher, W.H. “Are Women Patients With Cardiac Disease Treated Fairly?” Chicago Medicine, Vol. 98, No. 13, 1995
- Wehrmacher, WH “Women and Heart Disease: Shifting Paradigm in the Twenty-first Century}. Gender Medicine 2012 vol9#5 pp 385-396
- Wehrmacher, WH. “Essence of Progress in Geriatric Cardiology.” J Geriatric Cardiology 2012, volume 9
- The Digitalis Investigation Group “The Effect of Digoxin on Mortality and morbidity in Patients with heart Failure” N Engl J Med 1997. 336:525-533
- Wehrmacher, W.H. Digitalis Treatment Decreases Mortality and Morbidity in Heart Failure Patients. Reanalysis of Digitalis Treatment. Cardiology 2007 108(3): 157-158
- Ahmed, A., Gambassi, G., Weaver, M.T., Young, J.B., WEHRMACHER, W.H. and Rich, M.W. “ Effects of Discontinuation of Digoxin Versus Continuation at Low Serum Digoxin Concentrations in Chronic Heart Failure”. Am J Cardiol 2007:100 280-284
- Jepson EM “MER 29” Proc Roy Soc. Med 1962, 55:480-484
WILLIAM H.WEHRMACHER, MD, FACP, FACC is a clinical professor of medicine and adjunct professor of physiology, Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois. He is American board certified in internal medicine and cardiovascular disorders. His initial research, while at the University of Iowa was in muscle atrophy and regeneration. He served active duty as a medical officer in the U.S. Navy, with his last assignment as head of the section of cardiology in the naval hospital in Oceanside, California. Following his return from two tours of US naval duty, he became faculty at Northwestern University Medical School until 1970, after which he became clinical professor of medicine at Loyola.